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Int Public Health J 2013;5(4):399-412

ISSN: 1947-4989 © Nova Science Publishers, Inc.

Child abuse, neglect and maltreatment health service in Australia: A literature review Jing Sun, PhD1 and Nicholas Buys, PhD2 1

School of Public Health and Griffith Health Institute, Griffith University, Gold Coast campus, Parkland, Gold Coast, Australia 2 School of Human Services and Social Work, and Griffith Health Institute, Griffith University, Parkland, Gold Coast, Australia

Abstract This paper reviews child abuse, neglect and maltreatment health service practice in Australia. Child abuse, neglect and maltreatment and the need to protect children from harm and prevent abuse and neglect has become a significant public health concern. This paper reviews current clinical and community practice in Australia in the following aspects: clinical governance, workforce development, early prevention and intervention, partnership, communication and coordination, and core activities development. It is recommended that the framework for child protection work should include the following: 1) Develop health service capacity with institution: Each health service district, hospital and departments need to develop service roles. 2) Develop district and department governance procedures. 3) Professional training provision. 4) Multi-disciplinary teamwork. 5) Develop personnel role and responsibilities package within each department 6) Stipulate clinical handover and care coordination procedures and 7) Develop early identification and early intervention strategies. Keywords: Child abuse, neglect, maltreatment, health service

Introduction

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Correspondence: Jing Sun, PhD, School of Public Health, Griffith University and Griffith Health Institute, Griffith University, Gold Coast Campus, Parkland, Q4222 Australia. E-mail: [email protected]

Child abuse and neglect, and protection of children from the same, has become a significant clinical and community concern both in Australia and overseas (14). It is estimated that the prevalence of child physical abuse Australia ranges from 5-18% (5,6), prevalence of child neglect ranged from 2% to 12% (6,7).The prevalence estimates of child emotionally maltreated are quite different, ranging from 6% (8) to 17% (6); The prevalence of male child abuse was 1.4-8.0% for penetrative abuse and 5.7-16.0% for non-penetrative abuse, and prevalence rates female children was 4.012.0% for penetrative abuse and 13.9-36.0% for nonpenetrative abuse (1-4). Given the significant impact

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of early experiences of violence, abuse and harsh parenting regimes on later development, it is important that children are protected effectively from potential harm. Health services play a crucial role in recognising such harmful situations and taking immediate action to ensure the physical safety of children and minimize the long term emotional harm that accompanies abusive family, community, and social contexts. It is a common practice that Child Protection Health Services provide reporting and documentation to child protection service or child welfare services, assessing and diagnosing the children needing protection, investigating matters where a child is at possible risk of significant harm, and referral of children and families to social and health services that provide for the ongoing safety and well-being of the children. However, using an integrated approach to provide health services in child protection has not been evaluated. Physicians and nurses in many countries are legally required to refer suspicious child abuse or neglect cases to designated child welfare agencies. Reporting of child maltreatment is a challenging task (9,10), but protect children from harm becomes priority. Queensland Health, as a key stakeholder in the child protection work, has provided services in identification and reporting of suspected child abuse and neglect. To continue this role, a contemporary and effective service model to incorporate strategies and implementation plans in child protection is needed. The aim of the Child Protection Service Delivery Project was to develop a comprehensive and effective health service model for a health district in Queensland Health. It is critical that this framework is evidence-based and informed by the best evidence and practices in child protection. This review of literature was undertaken in order to support the project team in service framework development and implementation.

Aims of the literature review The main objective was to review the service delivery model in child protection in order to;

1. Inform and support the development of child protection service delivery framework in a Health Service District in Queensland. 2. Ensure the model is evidence-based and encompasses current best practice from other countries.

Methods An extensive national and international literature search was conducted during June 2007-June 2008 using a variety of databases including academic databases [Medline from 1966 to December 2007, ProQuest from 1980 to 2007, Science Direct 1980 to 2007, Balckwell Syndergy from 1966 to 2007], Australian databases [Australian Institute of Family Studies Library Catalogue, Australian Public Affairs Information Service, Australian Family & Society Abstracts, CINCH (Australian Criminology Database), National clearinghouses in the fields of child protection, health and domestic violence], and international databases [Care Data, Child Abuse, Child Welfare and Adoption (NISC), Educational Resources Information Clearinghouse, National Criminal Justice Reference Service, Sociological Abstracts, Social Services Abstracts]. Search words for identifying the research on organizational risk factors, management, recruitment and assessment included child and worker, staff and child, exploitation and institutions, recruitment and child, actuarial and child, and actuarial and risk and assessment. For identification of research on childrelated and perpetrator-related risk factors, the search words included child abuse and child abuser. The key words “child abuse”, “physical”, and “neglect” were used to search the literature. The results published before 1980 and in language other than English were used. Articles identified in the search were subdivided into Clinical governance, Workforce development, Early Prevention and Intervention, Partnership, Communication and coordination, Core activities, and Culturally and diverse background population. Articles with core activities were sought with the terms “case management” or “risk assessment”. Additionally, the Child Abuse Quarterly Review of research on child maltreatment and the journal “Child

Child abuse Abuse and Neglect” from January 1995 to December 2007 were also reviewed.

Current knowledge and practices No service framework at a district level was available either from literature review or from interstate. Therefore, the research team was required to determine relevant topics and issues to guide the selection and examination of the literature. After consultation with Child Protection Project team, the concept of Child Protection Service Delivery Framework was interpreted to have the following core dimensions: 1. 2. 3. 4. 5.

Clinical governance Workforce development Early prevention and intervention Partnership, communication and coordination Core activities

Clinical governance Clinical governance is the set of processes and systems that ensure the safety and highest quality of the process of care. It includes the systems for accountability, oversight and systematic improvement of care and a set of checks and reviews, whereby teams and communities of clinicians oversee and systematically improve the processes and practices of care (11). It was introduced in the 1990s in the National Health Service in the United Kingdom and has become popular in the UK, Canada and Australia (12). Clinical governance is closely associated with functional health service units including the ward, unit, department, health centre and clinic. The governance of all units begins at the highest level, requiring the leadership to set up organisational agendas for corporate, district and clinical governance. Having adequate reporting mechanisms and reviewing clinical and organisational performance through accurate data on a regular basis are preconditions for effective leadership. Governing authorities need to ensure that the organisation is performing effectively, services are being delivered

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according to predefined standards, and mechanisms are in place to take remedial action when problems are encountered. Describing the clinical governance framework for government, district and area service level in explicit terms is important for a number of reasons. First, it provides a clear and transparent communication of the organisation’s intentions and expectations in relation to the delivery of care to all stakeholders. Second, it clarifies roles and responsibilities of consumers and staff across the organisation while explicitly demonstrating the value and contribution they bring to the service, and the interdependence of each person’s roles and responsibilities. Third, it allows operationalization through the inclusion of relevant elements of the clinical governance framework in job descriptions, staff selection processes, performance review, education and training needs analysis, building of staff and service capacity, and testing and improvement of the framework’s elements. The Australian Council of Healthcare Standards (13), in 2004, defined clinical governance as “the system by which the governing body, managers and clinicians share responsibility and are held accountable for patient safety, minimising risks to consumers and for continuously monitoring and improving the quality of care.” The application of clinical governance in a health care setting in Australia is new and the success of its implementation has not been evaluated. But a number of common principles have been proposed across Australia (14): 1. Collaborative relationship between clinicians and managers in which the specific roles and responsibilities of each are made explicit, are understood by the other and are complementary, and where the highly trained, skilled clinicians provide increasingly complex, evidenced-based care to high-risk patients in collaboration with managers who have the high level training and skills to manage and to change highly complex, high-risk health systems (15). 2. Safeguarding principles in clinical risk management, where doctors play a crucial role in protecting children from abuse and neglect (16). There is a legal and professional duty for all doctors to ensure that advice

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Jing Sun and Nicholas Buys provided, either to the child or young person or to their parents or carers, is appropriate and has taken into account any impact that this may have on the ultimate safety of the individual (16). 3. Strengthening the roles and responsibilities of clinicians in clinical governance, which has been identified as the mechanism to systematically improve standards of clinical care (17). Its components are evidence-based practice, audit, risk management, mechanisms to monitor the outcome of care, lifelong learning among clinicians, and systems for managing poor performance. 4. Monitoring and clinical supervision of nurses, the importance of which has been emphasized in past decade in a range of United Kingdom government and professional policy documents (17). 5. Maintaining effectiveness in clinical governance, where the medical audits were the first type of activity implemented in the National Health Service in United Kingdom. It is a process that strives to improve patient care and outcomes through systematic review of care against explicit criteria, the implementation of change at an individual, team, or service level, and further monitored to confirm improvement of service delivery. However, opinions about its effectiveness are mixed in United Kingdom (18), many seeing audit solely as an educational exercise for junior doctors and having a limited contribution due to lack of methodological rigour and the poor quality of resultant recommendations. Those with a more positive view saw national audits as especially useful, particularly when they had been developed with clinical input. Others highlighted the benefits of audits that were able to identify areas of clinical risk or explored a problem arising from a clinical incident in detail. Audit meetings were one mechanism for bringing together departments on different hospital sites, providing a building block for standardisation of services. Effective audits were seen as those that involved the whole team, including other

health care professionals, and had consultant input into both the conduct of the audit and the implementation of the recommendations (18). 6. Facilitation of a more conducive cultural climate by the use of a variety of approaches, including reviewing and aligning policies, structures and processes within a clear vision and framework of goals related to quality improvement, reviewing and celebrating positive behaviours, involving staff in the process of change with support for any training and development needs, improving the effectiveness of communication across the organization and providing teams with time and space to reflect upon their performance. All these have been shown to have a positive effect (19-21). Clinical governance includes systems for accountability, oversight and systematic improvement of care (15), where the use of sound evidence as a basis for management of decision-making is been increasingly acknowledged. A vital focus in effective application of clinical governance principles to the development of enhanced systems of performance management for nursing, medical and technical staff, including staff appraisal and ensuring continued professional development (15). Clinical governance has been found critical to the successful development and implementation of an effective “system” approach to patient safety in health care (22). Developing clinical governance at corporate level rests on the core processes of clinical audit, clinical effectiveness, clinical risk management (CRM), quality assurance, and organisational and staff development. CRM is a key driver of patient safety processes within a clinical governance structure. There is a variation observed in the knowledge, beliefs and attitudes of experienced staff concerning clinical governance and CRM processes because; 

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The clinical governance and CRM processes currently being operationalised in the Australian health care sector are relatively new in Australia; There is a lack of attention to these issues in the Australian child protection literature;

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There is a lack of educational opportunities at both undergraduate and post registration levels for nurses to develop knowledge and skills relevant to clinical governance and CRM; The predictable resistance of a minority of staff to change (12,23).

Workforce development Health care workers, ranging from clinical staff who are responsible for conducting specialist medical investigations, to nurses working the community in positions such as school nurses, midwives and health visitors, have been recognised as having a key role in the child protection service internationally and in Australia. While child abuse work may constitute one of many responsibilities, nurses and paediatricians are often the first professionals to identify children who have been or are at significant risk of child abuse and neglect. However, the potential for nurses and paediatricians to fulfil this role in many settings is hampered by a perceived lack of training around child protection (24).Most studies show that the training for child protection workforce is inadequate in many countries, and has highlighted the need for adequate for initial and continued training in the identification, assessment and intervention in child protection, for all health professionals in primary and tertiary health care in regular contact with children,(25-27). The findings from inquiries and research suggest that in order to provide an effective child protection service, primary care workers need both the skills and knowledge to identify cases of child abuse and to know their roles and responsibilities, as well as how to liaise with other agencies involved in child protection. Fifty eight percent of services in United Kingdom did not have enough trained nurses (28). It is particularly important that front line nurses are well trained so that they can draw the attention of designated child protection staff to any cases of concern. Seventy percent of services nationally did not have enough trained nurses at this level. Eightfive percent of services in Accident and Emergency departments did not meet the standard training in child protection service (29). In the United Kingdom, with identification of training needs of already

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qualified nurses in the field of child protection (30, 31), it has been suggested that mandatory qualifying and in-service training should be provided to enable nurses to identify, assess and refer children for protection. The Royal College of Nursing (28) has produced guidelines with regard to the extent and level of training required by nurses in child protection. Further, given the rising scale of expectations placed on general medical practitioners (GPs) in taking on responsibility for child protection, it is essential to provide them with the skill, knowledge, attitudes, and values in this area of practice. However, a survey conducted in Canada found that among 16 medical schools, only 3 programs had mandatory clinical training for residents, and nine programs offered electives in child protection which were taken during the previous year by only 4.7% of respondents (32). Overall, only 26.8% of the residents have had any kind of clinical instruction in child protection at any time during their medical training. Over 91% of residents and 85% of fourth-year residents have indicated their need of further training in this area. Within Australia and New Zealand, advanced training in child protection workforce falls within the scope of Community Child Health. Recently, advanced trainees who work under the Specialist Advisory Committee for Community Child Health are required to complete 3 months of training in child protection. The child protection paediatrician may participate in multidisciplinary meetings, and participate in shared decision-making. In their clinical work, they may be called upon to advocate for the child for services and assess the development and behaviour of children who may have experienced abuse or neglect (9,33). One-third of CP paediatricians have reported receiving no training at all in child protection, and two thirds of CP paediatricians have received less than 4 months of training prior to completing their FRACP. Those paediatricians contribute to decision making with other child protection stake-holders in multi-agency meetings, and 50% of paediatricians indicated that they had less than adequate training for this role prior to FRACP (9, 33).Most paediatricians spend half of their allocated child protection time assessing children referred to the child protection system from health services. Only 13% of their working week is spent on

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the ongoing medical follow up of these children. In addition, only 50% of paediatrician continue to manage behavioural or developmental problems identified in these children beyond 6 months (9) suggesting that half these high-risk children receive long-term management elsewhere. Doctors who take on such tasks need additional opportunities for training and professional development, and a means of accreditation that confirms their expertise to clinical and forensic colleagues and to the judiciary. Nurses in Australia, who have considerable contacts with children, such as midwives, school nurses and nurses in paediatric wards or acute hospitals did not provide services in child protection, reflecting the fact that these services are provided by other departments (24). The challenge to provide adequate training to nurses who have identified a need for further knowledge about child protection issues is great, especially given a lack of consensus among most groups of nurses as to what training they require.

Early prevention and early intervention The early identification of child maltreatment and early intervention to reduce the degree of harm in children is critical to child’s physical and psychological development (29). The main strategies in early identification and intervention discussed in the literature are identification of children and parents who fall into high risk groups and identification of risk factors. Child maltreatment is usually the result of interaction of many risk factors, such as presence of a disability (34), a parent with substance abuse and/or depression (35), intimate partner violence within the family (36), residence in dangerous neighbourhoods or poor recreational facilities, and poverty and associated burdens (37). The family, community and the health department are collectively responsible for the children’s safety within their families. When the child maltreatment occurs and an adult fails his/her role to protect a child from harm, child protection system becomes responsible to provide service response by providing primary, secondary and tertiary services.

The goal of primary health services is to provide support and education for children and families before problems arise. In many cases, primary services prevent abuse and neglect occurring, are offered to everyone, and include ante-natal services, maternal and child health services and human relationship education in schools. Community education and awareness programs focus on addressing community attitudes towards violence, children's rights and physical punishment which are associated with child abuse. These programs educate the public about alternatives to abuse, changing social attitudes towards violence, and encourage community debate about issues such as censorship, family violence, substance abuse and drug use, etc. Physicians can help prevent child maltreatment in several ways (38). Establishing a good relationship with a family provides opportunities to observe parent-child relationship and identify risk of potential harm from adults. In many countries, all new births are notified to the nurses and they have a minimum of five contacts during the first year of life which take place at prescribed times, although in practice there may be more frequent visits if necessary (39). School- aged children are followed up through the school nursing service, which plays an important role in child protection due to the routine contact with all young children and their families (40). For example, in Ireland, a breakdown of time spent on domiciliary child development visits shows that 82% of time is given over to developmental checks, 1.5% to antenatal care, 14.7% to visiting vulnerable families and 2.1% to family surveillance (41). Parental education is useful to help with diminishing the risk of child abut and maltreatment. Hospital based programs can be developed to educate parents about infants behaviours and the parental methods to prevent abusive physical injury. Health check-up can provide opportunities to check psychosocial risks, such as parental depression, substance use, domestic violence, financial strains and stresses. However, the primary care role of advising and supporting parents to prevent poor child health care practices and child maltreatment has not yet been evaluated. Gough (42) in an extensive review of the literature on child abuse interventions suggests that interventions such as education and support may not

Child abuse be evaluated because of the difficulties inherent in measurement of their effectiveness. Nurses can refer to statutory and voluntary agencies before any problems arise and they may play an effective role in primary protection of children (43). The Dublin-based Community Mothers’ Programme provides an example of how nurses’ work effectively through the identification of community needs, and initiation and referral of children and families to support programmes (43). There are several types of service provision for child protection at a primary health care level (44): 

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Universal (core) health visiting: The new birth visit was the cornerstone of the universal health visiting service, which predicted more postnatal home visits and more frequent group and community-based activities. Teamwork delivering core service: The core service was delivered, in most instances, by the health visitor in conjunction with others, including members of the wider primary care team. Where health visitors led a skill-mix team, fewer scheduled home visits occurred, but there were more group and community activities overall. Extra health visiting: Services included additional home visits by health visitors and by other team members for service provision with regard to postnatal depression, breastfeeding, parenting education, sleep or behaviour problems, domestic violence, drug users and support, menopause, weight management, men’s health, language support, speech and language development, learning difficulties, mental health, multiple births, rural health and sexual health.

Secondary prevention is concerned with the early identification and appropriate referral of families once there is evidence of risk of child abuse and neglect. Secondary health services include in-home family support, counselling, respite care and various parenting and self-help groups. The secondary role of the nurses and paediatricians in early detection of families at risk is grounded in their expertise of normal emotional and physical development of

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children in the context of their families, as well as in an in-depth knowledge and awareness of injuries or behaviour likely to be non-accidental in nature (45). Currently, reporting a child on an “at risk” is mandatory in Australia (45,46). In the presence of an ‘at risk’ reporting, there is a formal mechanism for differentiating between ‘vulnerable’ and ‘at-risk’ children. Consequently, a family may be protected from the situation as ‘vulnerable’ and/or ‘at risk’. However, in many Western Countries, the need to differentiate these criteria remains largely unarticulated. This has led to nurses and paediatricians retaining responsibility for child protection in situations where specialist intervention is required. Tertiary prevention deals with minimizing disabilities. Greenwalt, Sklare, and Portes (47) described the current practice of some mental health practitioners in the treatment of cases involving physical child abuse in America. The family is considered the primary client most frequently with the focus of the family therapy to stop the abuse and to improve family relationships. Whether this focus should be considered the primary therapeutic goal needs further longitudinal research on the abused child. One would expect physically abused children to receive the help needed to stabilize their lives and become productive members of society as soon as possible. However, while some authorities recognize the importance of providing treatment for the abused child (48), little can be found in the literature about the treatment actually provided to the victim (49). White (50) notes mental health services to the abused child only as a part of foster care, residential care, or day care but not in the context of health service. Greater emphasis appears to be placed on the treatment of the parents and the safety of the child (51) than on overcoming the effects of the abuse on the child.

Partnership, communication and coordination Interagency coordination and collaboration is a significant issue for the provision of child protection

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and family support services. A coordinated response to the problem of child maltreatment can produce more effective risk assessment, greater efficiency in the use of resources, improved service delivery by the avoidance of duplication and overlap between existing services, clarification of agency or professional roles and responsibilities in front-line problems and demarcation disputes, and the delivery of comprehensive services. The structures or mechanisms that facilitate interagency collaboration and coordination are referral protocols, case conferencing, and the development of multidisciplinary teams. The formal referral protocols between health departments and social workers are mostly the primary means of communication. Informal linkages in conjunction with formal communication structures appear to be an effective partnership and coordination between agencies (52). The collaboration between medical evaluation for abused children and local child protection social (CPS) workers is needed, and to achieve agreement between paediatricians and CP workers are critical to identify the cases and improve the services (53). Standardising decision making, information sharing, consensus decision making, mediation by an administrator in the absence of consensus, rational discussions among members of the team and supportive attitudes towards other members, leading role played by the persons with most first-hand knowledge about the case handled, and the decisions made are respected despite the status of the person in team, all lead to better service provision (54). In Queensland, where child protection and adult mental health are the responsibility of separate government departments-the Department of Communities and Queensland Health, workers engage in collaboration to provide a wide range of services and supports focusing on adult mental health, child protection, family counselling and support, child health and mental health, and legal and financial assistance (55). The provision of these various supports is delivered via a highly fragmented and decentralised network of over 100 government (federal, state and local) and community-based programs, services and agencies. In some respects, the respondents’ description of their experiences of interagency collaboration was encouraging. In half the cases reported, respondents

identified that either no issues had arisen, or that collaboration had resulted in an improved outcome for the client or a positive collaborative process for the workers. This finding supports previous research, indicating that collaboration can be rewarding and beneficial for both workers and clients. However, in one-third of cases communication was cited as a problem and support previous findings (56-58) which indicate that information sharing, communication, and negotiating issues of confidentiality are crucial to a successful collaborative relationship. The second most commonly cited difficulty was the need for role clarity, including boundaries and leadership. This result supports the findings of Mizrahi and Rosenthal (59), which found leadership to be the most important factor for successful coalitions. This raises the questions of who the leader should be, how leaders should be chosen, and the scope of the authority to be bestowed. It is evident that effective communication and collaboration between health professionals on child protection issues is related to organisational level strategies, case level strategies, inter-professional relationships, staff training and supervision, types of knowledge required, and understanding of the interdependent needs of parents and children (55). Policy and practice is closely linked to effective partnerships. With high incidents of child maltreatment in Queensland (60), the state department of health, hospital-based child protection teams, nurses, and medical practitioners are increasingly asked to evaluate and treat child abuse and neglect despite their lack of formal training. In an effort to manage increased caseloads, other disciplines have trained paraprofessionals and lay people such as parent aides, lay therapists, and lay health visitors to provide services to abusive families. These workers have been shown to be fully capable of identifying abusive situations, and have alleviated workloads and provided additional services. In Australia, Departments of Health (DOH) plays a coordinating role in addressing child abuse and domestic violence through developing Mental Health Policy and Framework, and establishing partnerships with other agencies and service uses. The partnership was particularly in areas such as multi-professional training, service delivery, continuation of health and social services for families, and referrals. One way of

Child abuse achieving closer cooperation among the various agencies involved in child protection work is through the establishment of ‘multidisciplinary’ or interagency teams or meetings (61). Most of the literature emphasizes the efficiency of this multidisciplinary approach to case consultation and its positive effect on service delivery (61). There are several guides to the development and implementation of a multidisciplinary child protection team. One model is case consultation teams. These teams focus on case conferences, service development, and work to enhance interagency collaborations (61). Another model is treatment teams, often in hospitals, which collaborate on treatment plans for abused children and their families. They may also provide some long-term case management (62). A third model is resource development teams. These address the issue of child maltreatment through public education and advocacy. Members may be professionals working in the field or other citizens (63). Their program strengthens natural support networks through self-help groups and skills training sessions. The literature also describes mixed model teams that combine the above functions. Child maltreatment in all its manifestations constitutes a diagnostic and therapeutic problem to all hospital personnel caring for children and adolescents. To optimise practical procedures and to ensure child protection independent of decisions made by any single person, several Austrian hospitals have formed child protection teams or child abuse and neglect teams. In 1999, the Federal Ministry for the Environment, Youth and Family published a recommendation to install Child Protection Team (CPT) in all paediatric departments in Austria and provided a set of guidelines to assist CPT in carrying out their work in paediatric hospitals. These guidelines currently form the constitutional basis of CPT in 68% of all Austrian paediatric hospitals. The CPT team comprises the following professionals groups: paediatricians, paediatric surgeons, a child and adolescent psychiatrics, psychologists, psychotherapists, nurses, a social worker and a secretary. The CPT is available only to inpatient and was founded principally as a tool to provide support to the staff on the individual wards of the departments involved. Inpatient data from CPT functioning in hospitals are relatively scarce in the literature. The

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detailed data about the functioning and effectiveness of CPT are available only from the USA and Canada. Unfortunately, in its current form the function of CPTs lacks a suitable quality assurance structure (both qualitative and financial-structural), as has also been documented in US CPTs. An improvement in this could ensure a better detection of maltreatment, a more appropriate handling of the whole problem and guaranteed protection of the children concerned.

Core activities Nurses and paediatrician are often the first contact of children who are abused and neglected, and their education provides them with a broad base in assessment, planning, implementing and evaluating health care and nursing care in holistic way. They are responsible for primary, secondary and tertiary level of protection. The bulk of the responsibility in identifying and managing child maltreatment therefore lies with the health care teams. There are many indicators that could help health professionals to identify the children at risk of maltreatment. These include inconsistent history, delay in seeking attention, parent-child interaction, and mismatch in history and examination. However, there has been a lack of clarity about the purpose and appropriate use of indicators of concern. For example, in Emergency department (ED), ED physicians limited their documentation to a single presenting complaint, and it was difficult to be certain that a particular indicator was looked for and not found (e.g, whether the child had an unclothed examination or only the symptomatic limb was examined). The documentation of childhood injuries in the ED is inadequate, making any assessment of abuse difficult. On review of the medical record, there was high percentage of children who had one or more indicators that merited further analysis before a diagnosis of accident could be assigned; however, only 0.9% of children were referred to further examination. The poor referral rate in ED suggests that ED and orthopaedic staff are unaware of the significance of the indicators of maltreatment. In a study conducted in United Kingdom (64), it has been found that a large number of the protocols in ED department included long lists of signs and

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symptoms of abuse with no guidance on how to use these. Those with practical value included a short checklist, with clear guidelines on what to do if concerns were identified. Some indicators were very specific (for example, children under 1 year with a fracture, burn or scale), while others were more descriptive (for example, the parents behaviour gives rise to concern). One included recognised risk factors (for example, teenage parents, low income, or prematurity) as well as signs and symptoms, but gave no indicator on how these were to be interpreted. Tertiary protection in the Australian and New Zealand context consists of medical follow-up for children entering the child protection system, and monitoring of the development and behavioural progress in these children beyond 6 months, involvement of preventative child protection programmes which include programs on high-risk families with young infants and child protection research (65). Most paediatricians who are doing tertiary protection may also get involved in the advocacy for the child for services through joining in multidisciplinary meetings, and participate with other child protection agency stake-holders in decisions aimed to achieve the best child protection outcomes (65). The management of maltreated children has a number of options. For both sexual and physical abuse, cognitive-behavioural therapy (CBT) has dominated as the treatment with the most empirical validation. Parent training, in which parents are taught how to behaviourally specify goals for change, to track target behaviours, to positively reinforce prosocial conduct, and to punish or ignore their children’s aversive behaviours have also been extended to include coping skills, self-control skills, communication skills training and psycho-education (66). Some interventions have been developed specifically for children who have been physically abused. These include peer training, a school-based intervention that uses pro-social peers to help children who are withdrawn to develop social skills (67). For children up to five years of age, a therapeutic child development program has been developed to provide an intensive milieu of services, such as nutrition, health care, developmental therapies, and case management, provided by responsive adults (68).

Group treatment has been a typical modality of intervention for sexual abuse given its cost effectiveness and potential to reduce stigma. The theoretical orientations of group therapy have varied widely and include most commonly eclectic treatment models comprising various combinations of the following components: psycho-education regarding sexual abuse and sexual abuse prevention, exploration of the abuse experience, exploration of feelings, art therapy, play therapy, role plays, problem solving, puppet work, writing exercises, and behaviour management (69, p.674).

Service delivery model for child protection Based on the evidence from the literature review it is recommended that every health district and hospital have formal surveillance and accountability procedures or a clinical governance framework to improve quality and safety. To succeed, these frameworks must: 1) devolve governance and performance monitoring to the level of clinical units or departments where care is provided and whose staff bears the ultimate responsibility; 2) feature practice-relevant, data-driven agendas that actively seek involvement and innovation on the part of practising clinicians, and; 3) require hospital executives, clinical governance units and quality improvement coordinators to sponsor and support quality and safety activities within units. A relevant action plan should be developed for improving quality and safety and implement the clinical governance framework incorporating work force development and early identification and intervention into the implementation plan (70). This plan may include; 

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Develop service delivery capacity: health service districts, hospitals and its departments should develop delivery capacity in relation to facilities, staffing, and management. Develop district and department governance procedures: The governance structure and procedure should be developed from the state government executive to the district and health area managers level. This procedure

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should inform practice based framework and be implemented to the hospitals and districts. Professional training provision in child safety: Health department, universities, specialty collages, and medical societies should collaborate in forging new training programmes and career paths that focus on optimizing quality and safety. A key reform is to enable doctors, nurses and allied health professionals to more effectively undertake high-order bedside tasks that require specialised training by devolving and distracting, low-order clerical and nonclinical procedural tasks to appropriately trained assistants. In times of future shortages of specific groups of skilled clinicians, professional boundaries will need some renegotiation in situations where evidence confirms that tasks previously considered as the exclusive province of one type of practitioner can be safely carried out by other groups. Develop multi-disciplinary teamwork: Interdisciplinary team activities should be developed to reduce the risk of harm of children. Education and training should be provided to train multidisciplinary team’s safety procedures, team skills and communication skills. Establish clinical orientation procedures: All hospital departments should provide all newly appointed clinicians and nurses with a multidisciplinary orientation and information package that outlines departmental policies and procedures and personnel roles and responsibilities. Develop clinical care coordination procedures: All hospital departments should have clear procedures for (1) clinical handover between shifts for all disciplines and between different care teams, (2) accessing information and advice from external caregivers (e.g., general practitioner and specialists) with regards to the suspicion of children who are abused and neglected, (3) recording clinical information arising from emergency and paediatric department clinics, case conference and consultant visits and

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conveying it to others who need to know, and (4) transferring structured child information (clinic identification and assessment and community referrals) to general practitioners and other clinicians involved in the clinical care. Implement early identification and early intervention practices: The health system is often the only infrastructure that reaches children younger than three years and therefore can initiate programmes to promote early development and prevent risks. In new born infant health check and health visits program, early detection of child abuse and neglect should be one of paediatricians’ and nurses’ tasks. Once children are identified to be at risk of potential harm referrals to relevant early intervention program should be made. The parenting program (e.g., Triple P parenting program) should be made available in clinical and community settings. The educational system can promote child development by supporting comprehensive programmes for early child development. If the programmes are of high quality, have family involvement, and when needed provide health care and food supplementation or micronutrients, evidence suggests that disparities among the most disadvantaged children can be reduced before school entry. Linking early development programmes administered through the health system with programmes in the educational system increases the likelihood of building intervention follow-up for children at risk. To increase coverage of early child development programmes and improve their quality and effectiveness, better advocacy strategies, coordination mechanisms, and improved policy are needed. Research is required on approaches to delivering feasible effective child protection programmes at scale and on the effects of synergies on child outcomes. Implement pre and in-service training for health professional’s development: Training local frontline health and social services professionals, and providing support and consultation in child protection is needed.

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Health professionals who were trained with knowledge and skills increase the rate of detection of child abuse and neglect (70). Due to the key role that nurses have in protecting children, specialist training in child protection needs to be provided to all nurses including those who do not work directly with children. They need to be able to access information on child protection issues as required. Many nurses work either directly with children or indirectly in settings where children may be present (e.g., in private homes or in clinics where children accompany parents who are service users). This includes district nurses, community psychiatric nurses, and nurses working in the fields of learning disability and addiction. If they are to effectively contribute to the child protection agenda, they need at least some basic training about child protection, particularly around identifying children at risk and responding to any cases of suspected or alleged abuse of children. For new staff, participation in such training could be incorporated into their induction program, especially if an on-line training package is developed to provide basic knowledge about child protection issues.

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Submitted: April 05, 2013. Revised: May 15, 2013. Accepted: May 25, 2013.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.